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Dyspnea

Dyspnea. Chang Shim, MD Pulmonary Division Jacobi Medical Center. Dyspnea. Definition : Unpleasant or uncomfortable respiratory sensations

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Dyspnea

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  1. Dyspnea Chang Shim, MD Pulmonary Division Jacobi Medical Center

  2. Dyspnea Definition: Unpleasant or uncomfortable respiratory sensations A subjective experience of breathing discomfort. The experience derives from interactions among multiple physiological, psychological, social and environmental factors.

  3. Dyspnea Common complaint among the general population. 6%-27% of different gender and age strata (37-70 yrs) in the Framingham Study 2.7% of the emergency room visits Most common: asthma, myocardial dysfunction, COPD, interstitial lung disease

  4. American Thoracic Society Shortness of Breath Scale Grade Degree Description 0 none No trouble walking up a slight hill 1 mild SOB hurrying on the level or walking up a slight hill • moderate Walks slower than the peers; has to stop for SOB walking at own pace • severe Stops for breath after walking about 100 yards or after a few minutes 4 very severe Too breathless to leave the house or breathless on dressing or undressing

  5. Dyspnea: Direct Measurement Visual Analog Scale Not breathless---------------------------------------------Extremely breathless Modified Borg Scale 0 none 0.5 very, very slight • very slight • slight • Moderate • somewhat severe • Severe • very severe • very, very severe 10 maximal

  6. Physiologic Categories of Diseases Causing Dyspnea-1 Mechanical interference with ventilation Obstruction of airflow Asthma, emphysema Endobronchial tumor Tracheal stenosis Stiff lungs Interstitial fibrosis LV failure Lymphangitic carcinoma Resistance to expansion of the chest wall or diaphragm Obesity Pleural thickening Kyphoscoliosis Abdominal mass, ascites, pregnancy

  7. Physiologic Categories -2 Weakness of the respiratory pump Absolute Prior polio Neuromuscular disease- Guillain-Barre syndrome Myasthenia gravis, muscular dystrophy, SLE, Hyperthyroidism, hypothyroidism, multiorgan dysf Relative Pleural effusion Pneumothorax Hyperinflation (emphysema)

  8. Physiologic Categories -3 Increased respiratory drive Hypoxia Metabolic acidosis Stimulation of intrapulmonary receptors- infiltrative lung disease, pulmonary hypertension, pulmonary edema

  9. Physiologic Categories-4 Wasted ventilation Capillary destruction: emphysema, interstitial lung disease Large vessel obstruction: pulmonary embolism, pulmonary vasculitis Psychological dysfunction Anxiety-panic state, depression, litigation

  10. Mechanisms of Dyspnea Originates with the activation of sensory systems involved with respiration. Relayed to the higher brain centers for processing of respiratory-related signals and cognitive and behavioral influences shape the ultimate sensation.

  11. Evaluation of the Patient with Dyspnea History and physical examination: characteristics of symptoms, quality, intensity, duration, distress. Specific activities associated with dyspnea Quantify intensity of dyspnea Effect on life quality Cardiovascular vs pulmonary dyspnea, or both

  12. Special Studies-1 Pulmonary function studies Lung volumes and flow rates Diffusing capacity (DLCO) Arterial blood gases Cardiopulmonary exercise testing Bronchial challenge Maximal inspiratory pressure

  13. Special Studies-2 Imaging studies Ventilation-perfusion lung scan Chest CT, HRCT (high resolution CT) Gallium scanning Diaphragmatic fluoroscopy

  14. Special Studies-3 Cardiacevaluation Echocardiogram-for ventricular size and function, regional wall motion abnormalities Dobutamine stressechocardiography-regional wall motion abnormalities. Thallium perfusion scan Holter monitor Cardiaccatheterization/coronary angiography Plasma BNP or N-terminal pro-BNP most HF patients >400 pg/ml; normals 10 pg

  15. Special Studies-4 Sleep studies Esophageal pH monitor ENT examination Psychological assessment

  16. Treatment of DyspneaAltered Central Perception Cognitive-behavioral strategies Perception of dyspnea results in part from the effects of cognitive, emotional, and behavioral factors on the conscious awareness of the demand to breathe and the affective response to the symptom. Education about the disease process Teaching of the coping skills, for example, relaxation, distraction, reassurance

  17. Asthma • Reverse airflow obstruction • Bronchodilators, anti-inflammatory agents • Relieve chest tightness • Same as above • Control cough • Same, + cough meds & local anesthetics • Relieve anxiety • Anxiolytics: usually contraindicated • Rare exceptions: benzodiazepines, opiates

  18. Reduce Resistive Load Reverse bronchoconstriction. Decrease airway inflammation and edema Pharmacological therapy Inhaled beta2-agonists, short and long-act Inhaled anticholinergics Theophylline probably related to deceased operational lung volumes.

  19. COPD • Reverse airflow obstruction: anti-cholinergics (short and long acting), corticosteroids, long acting beta agonists, theophylline • Reverse hyperinflation/air trapping • Inhalation meds, Expiratory maneuvers, LVRD • Exercise rehabilitation

  20. COPD • LVRS (lung volume reduction surgery):NETT • Oxygen • NIPPV for acute exacerbation • Reduce ventilatory requirements: metabolism, V/Q, exercise rehab. • Central drive: depressants: benzodiazepines, opiates

  21. Treatment of Dyspnea Reduce ventilatory demand Increased VE or VE/MVC (maximal ventilatory capacity) correlates with exertional dyspnea. Reduce CO2 output, VD/VT (physiologic dead space), arterial hypoxemia, metabolic acidosis. Hyperventilation itself causes dyspnea.

  22. Reducing Metabolic Load Exercise training Improves aerobic capacity Reduces rate of rise of lactate levels with exercise Decreases exertional dyspnea Improves exercise tolerance Reduces VE per work rate primarily by decreasing breathing frequency. VCO2 and VO2 reduced at a given work rate=improved efficiency.

  23. Reducing Metabolic Load Supplemental oxygen during exercise Patients with chronic lung disease have reductions in blood lactate and VE

  24. Decreasing Central Drive Inhaled pharmacologic therapy Lidocaine may alter afferent information from the pulmonary receptors: Asthma Low dose opiates via nebulizers ? Fans: mechanoreceptors on the face or decrease in temperature of facial skin Improve efficiency of CO2 elimination VD/VT is increased. Slow deep breath Altered breathing pattern: slow deep breathing, diaphragmatic breathing, pursed lip breathing

  25. Decreasing Central Drive Oxygen Therapy Depress hypoxic drive from the peripheral chemoreceptors in the carotid body. Oxygen may blunt pulmonary artery pressure rise with exercise. Oxygen may improve ventilatory muscle function. Airflow over the face or nasal mucosa may ameliorate dyspnea.

  26. Decreasing Central Drive Oxygen Therapy As an adjunct to exercise training program. Prevents skeletal muscle deconditioning by increasing ADL. Criteria: PO2 =<55 mmHg or 56-59 mmHg with polycythemia or cor pulmonale. Flow rate should be adjusted to correct hypoxemia. Delivery by nasal canula, face mask, transtracheal catheter

  27. Decreasing Central Drive Pharmacologic therapy Opiates Respiratory depressants reduce the central processing of neural signals. Reduce VE & VO2 at rest and exercise. Endogenous opioids modulate dyspnea in acute bronchoconstriction. Opiates may alleviate dyspnea by blunting perception. Side effects: hypercapnea, altered mental status, constipation, nausea, vomiting, drowsiness Inhaled opiates are not effective.

  28. Decreasing Central Drive Anxiolytics May relieve dyspnea by depressing hypoxic or hypercapnic ventilatory responses. May alter emotional responses to dyspnea. Benzodiazepines failed to demonstrate consistent improvement in dyspnea. Poorly tolerated. May benefit individuals with respiratory panic attacks, but needs close monitoring.

  29. Reducing Ventilatory Impedance Reduce lung hyperinflation Dynamic hyperinflation during exercise or hyperventilation—auto-PEEP or intrinsic PEEP is important contributor to dyspnea. Surgical volume reduction Unilateral bullectomy, or lung volume reduction surgery (LVRS) benefits by reduction of operating lung volumes. Dyspnea decreased by reduced dynamic hyperinflation, improved chest wall mechanics and increased lung recoil and increased airflow.

  30. Lung Volume Reduction Surgeryin Emphysema

  31. Lung Volume Reduction Surgery

  32. Continuous positive airway pressure(CPAP) Low levels of CPAP relieve dyspnea in Acute bronchoconstriction in asthma, Patients weaning from mechanical ventilation, During exercise in advanced COPD. Benefits of CPAP are probably related to reduction in auto PEEP

  33. Improving Inspiratory Muscle FunctionStrength and Endurance Respiratory muscle weakness, fatigue and dyspnea Decreased body weight—decreased diaphragm mass, decreased intercostal muscle fiber size Weight loss of >10% of ideal body weight Improvement of respiratory muscle function with enteral or parenteral nutrition Inspiratory muscle training? Positioning: leaning forward position Partial ventilatory support Minimizing the use of steroids

  34. Obesity • Apple shaped, in contrast to pear shaped, is more burdensome to diaphragmatic movement. • Central respiratory drive: supernormal • Upper airway dimension: crowded, relaxed muscle • Airway dimension is related to lung volume. • Upright position, unloading of the diaphragm • CPAP (continuous positive airway pressure) prevents large airway collapse • Bariatric surgery

  35. Paralysis, Chest wall abnormality Reversible conditions, myasthenia, Guillain Barre: mechanical ventilation until recovery of neuro-muscular function Correct chest wall abnormality if feasible: pleural effusion, pneumothorax, flail chest NIPPV

  36. Diagnosis of Diaphragmatic Paralysis Unilateral: often asymptomatic VC sitting and supine Sniff test under fluoroscopy Sonography

  37. Sniff Test Not the cocaine variety Sniff is a potent, brief inspiratory maneuver everyone is familiar with. Monitor diaphragmatic movement (fluoroscopic imaging) from the patient’s side during sniffing. The paralyzed diaphragm moves up paradoxically while the intact diaphragm descends sharply.

  38. Dyspnea in Diaphragm Paralysis Body position or posture Exercise tolerance Stretch receptors in the muscles and tendons Activities: rest, sleep, exertion

  39. Diaphragm Pacer

  40. Hyperventilation Syndrome • Anxiety-panic attacks • Shortness of breath, tingling in finger tips, circum-oral numbness, dry mouth, globus hystericus, sense of doom. • In association with asthma, COPD, vocal cord dysfunction: management problem (beta agonist). • Important to dissociate asthma from hyperventilation: PEFR, paper bag rebreathing, slow expiratory maneuvers to prevent hyperventilation, ex. shee. • Pharmacologic: narcotics, benzodiazepines • Self-corrected once patient lapses into coma

  41. END

  42. Dyspnea Assessment Borg scale for severity Sensation: inability to inhale deeply inability to exhale properly Hyperinflation or air trapping in obstructive lung disease Position or posture, helpful, detrimental Bending over vs tripod positions in adults

  43. Dyspnea in Obesity Position or posture Activity Walking, climbing stairs Bending over Supine position with choking sensation Lateral decubitus with pendulous belly is better tolerated.

  44. Dyspnea with CHF Receptors for dyspnea in J receptors or airway or stretch receptors in left atrium Small airways dysfunction from peri-bronchial edema. Interstitial vs alveolar space edema Oxygen desaturation

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